penelitian anc di indonesia
TRANSCRIPT
-
8/9/2019 Penelitian Anc Di Indonesia
1/10
R E S E A R C H A R T I C L E Open Access
Factors associated with underutilization ofantenatal care services in Indonesia: results ofIndonesia Demographic and Health Survey2002/2003 and 2007Christiana R Titaley1*, Michael J Dibley1, Christine L Roberts2
Abstract
Background:Antenatal care aims to prevent maternal and perinatal mortality and morbidity. In Indonesia, at leastfour antenatal visits are recommended during pregnancy. However, this service has been underutilized. This study
aimed to examine factors associated with underutilization of antenatal care services in Indonesia.
Methods: We used data from Indonesia Demographic and Health Survey (IDHS) 2002/2003 and 2007. Information
of 26,591 singleton live-born infants of the mothers most recent birth within five years preceding each survey was
examined. Twenty-three potential risk factors were identified and categorized into four main groups, external
environment, predisposing, enabling, and need factors. Logistic regression models were used to examine the
association between all potential risk factors and underutilization of antenatal services. The Population Attributable
Risk (PAR) was calculated for selected significant factors associated with the outcome.
Results: Factors strongly associated with underutilization of antenatal care services were infants from rural areas
and from outer Java-Bali region, infants from low household wealth index and with low maternal education level,
and high birth rank infants with short birth interval of less than two years. Other associated factors identified
included mothers reporting distance to health facilities as a major problem, mothers less exposed to mass media,and mothers reporting no obstetric complications during pregnancy. The PAR showed that 55% of the total risks
for underutilization of antenatal care services were attributable to the combined low household wealth index and
low maternal education level.
Conclusions: Strategies to increase the accessibility and availability of health care services are important
particularly for communities in rural areas. Financial support that enables mothers from poor households to use
health services will be beneficial. Health promotion programs targeting mothers with low education are vital to
increase their awareness about the importance of antenatal services.
BackgroundThe proportion of child deaths occurring in the neona-
tal period-the first four weeks of an infants life, has
been increasing worldwide [1,2]. Antenatal care, a preg-
nancy-related service provided to pregnant women by
health professionals, is among the major interventions
which aim to prevent neonatal deaths and maintain the
health of women during pregnancy [3,4]. A review on
interventions for neonatal survival demonstrated that up
to 12% of neonatal deaths could be averted by the provi-
sion of antenatal care services at 90% coverage [3].
Antenatal care enables health professionals to identify
potential risks for the pregnancy or for the delivery and
to provide prompt treatment for women experiencing
health problems during pregnancy [4]. Through this ser-
vice, women will receive assistance in developing a birth
plan and be prepared for parenting after the childbirth
[4]. Other services provided include the provision of
* Correspondence: [email protected] School of Public Health, Edward Ford Building (A27), University of
Sydney, NSW 2006, Australia
Full list of author information is available at the end of the article
Titaley et al. BMC Public Health 2010, 10:485
http://www.biomedcentral.com/1471-2458/10/485
2010 Titaley et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.
-
8/9/2019 Penelitian Anc Di Indonesia
2/10
Tetanus Toxoid vaccinations, iron/folic acid supple-
ments and control of nutritional deficiencies [3,5].
Observational studies from both developed and devel-
oping countries have shown a protective effect of
antenatal care services on neonatal deaths [6-10]. Inade-
quate antenatal care has been associated with adverse
pregnancy outcomes [6,8,11]. Furthermore, studies from
India have shown that women who attended antenatal
care services had an increased likelihood of using
trained delivery attendants during childbirth, or having
an institutional delivery [12,13].
In Indonesia, at least four antenatal visits are recom-
mended during pregnancy [14,15]. Antenatal care is pro-
vided by health personnel through different modes of
service delivery, including the facility based and out-
reach services.
Descriptive data from the 2007 Indonesia Demographic
and Health Survey (IDHS) [14] has shown that, as in otherdeveloping countries [16-19], antenatal care services in
Indonesia are still underutilized. Approximately 95% of
pregnant women in Indonesia attended at least one
antenatal care visit; however only 66% of women had four
antenatal visits as recommended, which is lower than the
national target of 90% of women having at least four
antenatal care visits [14]. The proportion of non-atten-
dance at antenatal care services varied widely across pro-
vinces, ranging from 31% in Papua to less than 0.5% in
DKI Jakarta [14]. This study therefore aimed to examine
factors associated with underutilization of antenatal care
services in Indonesia. The results should provide insights
to policy makers about potential public health strategies to
increase the uptake of antenatal care services.
MethodsData sources
We used data from the Indonesia Demographic and
Health Survey (IDHS) 2002/2003 and 2007, which are
openly available from the Measure DHS website [20].
The IDHS is a five-year periodic survey used to collect
information from ever-married women aged 15-49 years
and ever-married men 15-54 years about demographic
and health status. Three types of questionnaires used
were the Household, Womens, and Mens Question-naire [20]. The Womens questionnaire included ques-
tions about womens demographic characteristics, their
reproductive history, pregnancy, postnatal care, as well
as immunization and nutrition. The sampling method of
the IDHS has been reported in detail elsewhere [21].
A total of 62,378 eligible women were interviewed for
these two surveys; 29,483 in the 2002/2003 survey [22]
and 32,895 women in the 2007 survey [14]. The response
rate of eligible women in the 2002/2003 and 2007 IDHS
was 98% [22] and 96% [14], respectively. In the present
study, information of 26,591 singleton live-born infants
of the mothersmost recent birth within five years pre-
ceding each survey was used. The most detailed health
services information is available for a woman s most
recent birth. Furthermore, this restriction aimed to
reduce recall bias of mothers about their pregnancies.
Variables
The primary outcome of this study was underutilization of
antenatal care services which included infants whose
mothers never attended antenatal care services and
mothers attending less than the four recommended
antenatal services [14,15]. Antenatal service referred to
any pregnancy-related services provided by skilled health
personnel, such as doctors, midwives, or village midwives.
We excluded those antenatal care services provided by
non-health professionals such as traditional birth atten-
dants. A sensitivity analysis was also performed for infants
whose mothers never attended any antenatal service forher last pregnancy within five years preceding each survey.
We adapted the behavioural model framework of
Andersen [23] for use of health services, to group the
factors potentially associated with not attending antena-
tal care services (Figure 1). Twenty-three potential risk
factors were identified and categorized into four main
groups, external environment, predisposing, enabling
and need factors. The variables included in the study
are presented in Figure 1.
A new household wealth index variable was con-
structed to rank households across the pooled IDHS
data. Using a Principle Component Analysis method [24],
weights were assigned to four housing characteristics
(source of drinking water, type of toilet, main material of
floor, main material of wall), and seven household assets
(availability of electricity, possession of radio, television,
fridge, bicycle, motorcycle, and car). A composite three-
category variable of household wealth index, i.e. rich,
middle and poor, and maternal education level, was
constructed to assess their association with the outcome.
Statistical analysis
Frequency tabulations were performed to describe the
characteristics of infants included in this study. Logistic
regression was used to determine factors associated withthe outcome. Bivariate and multivariable analyses were
conducted to assess the crude Odds Ratio (OR) and
adjusted Odds Ratio (aOR), respectively.
Using a hierarchical modelling strategy [25], the more
distal factors were first entered into the model to assess
their associations with the study outcome. Backward
elimination procedure was then employed to remove
factors which were not significantly associated with under-
utilization of antenatal services, using a significance level
of 0.05. A variable that represented year of survey was
retained in all models regardless of its significance level.
Titaley et al. BMC Public Health 2010, 10:485
http://www.biomedcentral.com/1471-2458/10/485
Page 2 of 10
-
8/9/2019 Penelitian Anc Di Indonesia
3/10
In the first model, the year of survey variable and the
external environment factor variable, i.e. the combined
region and type of residence, were entered (see Figure
1). Backward elimination method was conducted to
select factors significantly associated with the outcome.In the second model, thirteen predisposing factor vari-
ables were entered followed by backward elimination
procedure. A similar approach was used for enabling
and need factors. Interaction between maternal educa-
tion and household wealth index was also examined.
All of the OR, aOR and 95% confidence interval (CI)
were determined and weighted for the sampling prob-
abilities. Statistical analyses performed in this study used
the STATA/MP version 10.0 (2007) (Stata Corporation,
College Station, TX, USA). Survey commands were
employed for logistic regression models to adjust for the
sampling weights and cluster sampling design.
The Population Attributable Risk (PAR) [26-28] wascalculated for selected factors associated with the out-
come to estimate the proportion of underutilization of
antenatal care (ANC) services attributable to the factor
examined. Using the adjusted odds ratio (aOR), the PAR
was calculated as follows [26-28]:
PAR Proportion of infants whose mothers underutilized
ANC
=
aassociated with the factoraOR 1
aOR
( )
ResultsOf the 26,591 singleton live-born infants of the mothers
most recent birth within five years preceding each survey,
20% (95% CI: 18%-21%) were born to mothers attending
less than four antenatal care services and this included7% (95% CI: 7%-8%) of infants born to mothers who did
not attend any services. The percentage of mothers
attending less than four services decreased slightly from
20% in IDHS 2002/2003 to 19% in IDHS 2007.
Table 1 presents the baseline characteristics of mothers
included in this analysis. It shows that compared to
mothers from urban areas of the Java-Bali region,
mothers from other areas were more likely to underuti-
lize antenatal care services. Higher odds for not attending
the services were found in rural than in urban areas.
Among the socio-demographic factors, the odds for
underutilizing antenatal care services increased signifi-
cantly for mothers with low educational attainment and
from households with a low wealth index. A significant
interaction term was found between household wealth
index and maternal education (p = 0.02) (Figure 2). The
association between household wealth index and under-
utilization of antenatal care services was influenced by
maternal education level. An increased education level
has a greater effect for women from households with a
low wealth index compared to those from the wealthiest
households (Table 1 and Figure 2).
EXTERNAL
ENVIRONMENTENABLING FACTORS
Underutilization of
antenatal care services
Region and type of residence - Know where to go to seekhealth services
- Permission to visit healthservices
- Money to pay healthservices
- Distance to health services
- Transportation to healthservices
- Presence of companion
- Availability of care byfemale health workers
- Pregnancy complications
- Desire for pregnancy
NEED FACTORSPREDISPOSING
FACTORS
Socio-demographic:
- Maternal age at delivery
- Household wealth indexand maternal education
- Paternal education
- Parental occupation
- Maternal marital status
- Maternal final say on herown health care
- Birth rank and interval
Health knowledge:
- Frequency of reading
newspapers
- Frequency of listening to
radio
- Frequency of watching
television
- Knowledge of pregnancycomplications
- Knowledge of delivery
complications
- Knowledge of postdelivery complications
Figure 1 Theoretical framework of factors associated with underutilization of antenatal care services in Indonesia. Note: Framework
adapted from Andersen behavioural model [23].
Titaley et al. BMC Public Health 2010, 10:485
http://www.biomedcentral.com/1471-2458/10/485
Page 3 of 10
-
8/9/2019 Penelitian Anc Di Indonesia
4/10
Another significant demographic factor identified was
the combined birth rank and interval. Mothers of high
birth rank infants with a short birth interval were more
likely to underutilize antenatal services. However, a
reduced odds was observed for first birth rank infants
(aOR = 0.81, 95% CI: 0.70-0.93), compared to the sec-
ond and the third birth ranked infants with more than
two-year birth interval. Other factors significantly asso-
ciated with underutilization of antenatal services were
women with less exposure to mass media, women lack-
ing knowledge about obstetric complications, women
reporting physical distance to health facilities as a major
problem, women who reported they did not experience
any pregnancy complications and women who did not
intend to become pregnant at the time of pregnancy.
Similar findings were found for mothers who did not
attend any antenatal services (data not shown). An
increased odds of not attending antenatal care serviceswas found among women from the outer Java-Bali
region and from rural areas, women from poor house-
holds and with a low level of education, women lacking
knowledge of pregnancy complications (aOR = 1.46,
95% CI: 1.25-1.70, p < 0.001), women who reported
money to pay health services as a major problem (aOR
= 1.21, 95% CI: 1.05-1.39, p = 0.01), and women who
did not have any pregnancy complications (aOR = 1.44,
95% CI:1.16-1.78, p < 0.01).
Table 2 presents the PAR for selected factors asso-
ciated with underutilization of antenatal care. The com-
bined PAR of household wealth and maternal education
showed that in the population 55% of the total risk for
underutilizing antenatal care services was attributable
these two variables. The PAR increased along with the
reduction of household wealth index and maternal edu-
cation level. The PAR values presented in Table 2
should not be added, as this might cause misinterpreta-
tion of the results [29].
Discussion
Main findings
Our study demonstrated that factors strongly associated
with underutilization of antenatal care services were
region and type of residence, communitys householdwealth index and maternal education and combined
birth rank and birth interval. Mothers of infants from
the outer Java-Bali region, particularly from rural areas
were more likely to underutilize antenatal services.
A significant interaction between household wealth
index and maternal education was also found. Low eco-
nomic status was associated with increased odds of
underutilizing antenatal care services among mother
with a low education level. Furthermore, an increased
odds of underutilizing antenatal care services was
observed in mothers of high birth rank infants. Other
significant factors found included mothers less exposed
to mass media, mothers reporting money to pay for
health services as a major problem and mothers report-
ing distance to health facilities as a major problem.
Amongst the need factors, the odds for underutilizing
antenatal services increased among mothers who did
not experience any pregnancy complications. The identi-
fication of these factors is important to develop public
health strategies that address key issues which hinder
women from utilizing antenatal service in Indonesia.
Factors associated with underutilization of antenatal care
services
Outer Java-Bali region and rural residence were asso-
ciated with underutilization of antenatal services. This is
likely due to the shortage of health services aggravated
by the limited access in outer islands, especially in rural
areas. A study in Java [30] reported a shortage of healthcare providers which was reflected by a low density of
health professionals compared to the international stan-
dard [31]. In this present study, the problem of access
to services was confirmed by the increased likelihood
for underutilization of antenatal services among mothers
reporting distance to health services as a major problem.
A previous study has shown that distance and time to
the nearest health facilities influenced health services
utilization [32]. A qualitative study from West Java Pro-
vince found that in rural areas, a long travel time wor-
sened by poor road conditions prevented communities
from attending antenatal services [33]. These findings
indicate that the improvement of access to health ser-
vices as well as the distribution of health services and
personnel, especially in rural areas, should be a priority.
The role of household economic status on health ser-
vic es uti lizat ion has bee n reported in var ious studie s
[34,35]. An increased likelihood to underutilize antenatal
services along with the reduction of household wealth
index was also found in our study. Women from high
household wealth index were more likely to be able to
afford health services, and their associated costs, includ-
ing transportation costs [16]. Although the Health
Insurance Scheme for the Population or Jaminan Kese-
hatan Masyarakat (Jamkesmas), which is an insurancescheme provided to the poor or near poor communities
in Indonesia to give them free access to health services
has been implemented, our earlier study showed that it
did not improve the health seeking behaviour of some
poor communities, particularly those living in rural and
remote areas [33]. This might be due to the lack of
understanding of Jamkesmas and how it can be used by
some community members. Urgent attention to imple-
ment effective communication programs to support
appropriate use of this insurance scheme is required,
along with evaluation and monitoring strategies to
Titaley et al. BMC Public Health 2010, 10:485
http://www.biomedcentral.com/1471-2458/10/485
Page 4 of 10
-
8/9/2019 Penelitian Anc Di Indonesia
5/10
Table 1 Baseline characteristics, unadjusted and adjusted odds ratio (OR) for factors associated with underutilization
of antenatal care services in Indonesia, IDHS 2002/2003 and 2007
VARIABLE N (%)* UNADJUSTED ADJUSTED
OR (95% CI) P OR (95% CI) P
Year of survey
IDHS 2002/2003 (Ref) 12646 (47.6) 1.00 1.00
IDHS 2007 13945 (52.4) 0.93 (0.79-1.09) 0.37 0.87 (0.73-1.02) 0.09
EXTERNAL ENVIRONMENT
Region and type of residence
Java-Bali region: urban (Ref) 8101 (30.5) 1.00 1.00
Java-Bali region: rural 7386 (27.8) 2.76 (2.04-3.75) < 0.001 2.78 (2.05-3.76) < 0.001
Sumatera region: urban 2031 (7.6) 1.63 (1.17-2.27) < 0.01 1.63 (1.17-2.26) < 0.01
Sumatera region: rural 3584 (13.5) 4.57 (3.47-6.03) < 0.001 4.60 (3.49-6.07) < 0.001
Eastern Indonesia region: urban 1645 (6.2) 2.39 (1.51-3.79) < 0.001 2.39 (1.52-3.76) < 0.001
Eastern Indonesia region: rural 3845 (14.5) 4.86 (3.76-6.29) < 0.001 4.93 (3.82-6.36) < 0.001
PREDISPOSING FACTORS
Socio-demographic
Maternal age at delivery Mean SE = (27.2 0.07) 1.01 (1.00-1.02) < 0.01 0.97 (0.96-0.98) < 0.001
Household wealth index and maternal education
Wealthiest household, completed secondary education orhigher (Ref)
5137 (19.3) 1.00 1.00
Wealthiest household, completed primary or some secondaryeducation
4273 (16.1) 3 .47 (2 .63-4.56) < 0.001 2.15 (1.63-2.85) < 0.001
Wealthiest household, incomplete primary education or none 548 (2.1) 9.45 (5.82-15.35) < 0.001 4.01 (2.37-6.79) < 0.001
Middle household wealth, completed secondary education orhigher
1629 (6.1) 3 .76 (2 .72-5.21) < 0.001 2.36 (1.67-3.32) < 0.001
Middle household wealth, completed primary or some
secondary education
5738 (21.6) 6 .91 (5 .31-9.00) < 0.001 3.13 (2.30-4.25) < 0.001
Middle household wealth, incomplete primary education ornone
1584 (6.0) 17.86 (13.46-23.71) < 0.001 5.50 (3.86-7.83) < 0.001
Poorest household, completed secondary education or higher 425 (1.6) 10.24 (7.01-14.97) < 0.001 4.30 (2.87-6.45) < 0.001
Poorest household, completed primary or some secondaryeducation
4059 (15.3) 14.58 (11.16-19.05) < 0.001 4.75 (3.42-6.60) < 0.001
Poorest household, incomplete primary education or none 2326 (8.7) 37.76 (28.32-50.35) < 0.001 8.82 (6.10-12.73) < 0.001
Paternal education
Completed secondary education or higher (Ref) 9081 (34.2) 1.00 1.00
Completed primary or some secondary education 13237 (49.8) 3.30 (2.87-3.79) < 0.001 1.41 (1.19-1.66) < 0.001
Incomplete primary education or none 4199 (15.8) 7.73 (6.52-9.18) < 0.001 1.60 ( 1.31-1.95) < 0.001
Parental occupationUnemployed mother and working father (Ref) 14100 (53.0) 1.00
Working mother and working father 11820 (44.5) 1.19 (1.06-1.34) < 0.01
Unemployed father 581 (2.2) 1.71 (1.20-2.44) < 0.01
Maternal marital status
Currently married (Ref) 25953 (97.6) 1.00 1.00
Formerly married 638 (2.4) 1.85 (1.45-2.37) < 0.001 1.60 (1.19-2.16) < 0.01
Maternal final say on her own health care
Woman with partner/other (Ref) 8514 (32.0) 1.00 1.00
Woman alone 14200 (53.4) 1.09 (0.96-1.25) 0.19 1.23 (1.08-1.41) < 0.01
Partner alone/someone else/other 3860 (14.5) 1.37 (1.17-1.61) < 0.001 1.24 (1.05-1.47) 0.01
Titaley et al. BMC Public Health 2010, 10 :485
http://www.biomedcentral.com/1471-2458/10/485
Page 5 of 10
-
8/9/2019 Penelitian Anc Di Indonesia
6/10
Table 1 Baseline characteristics, unadjusted and adjusted odds ratio (OR) for factors associated with underutilization
of antenatal care services in Indonesia, IDHS 2002/2003 and 2007 (Continued)
Birth rank and interval
2nd or 3rd birth rank, > 2 year interval (Ref) 10751 (40.4) 1.00 1.00
1st birth rank 9139 (34.4) 0.86 (0.76-0.97) 0.01 0.81 (0.70-0.93) < 0.01
2nd or 3rd birth rank, 2 year interval 1570 (5.9) 1.95 (1.61-2.37) < 0.001 1.94 (1.58-2.40) < 0.001
4 th birth rank, > 2 year interval 4443 (16.7) 2.67 (2.37-3.00) < 0.001 2.08 (1.80-2.40) < 0.001
4 th birth rank, 2 year interval 687 (2.6) 4.74 (3.74-6.00) < 0.001 3.79 (2.88-4.99) < 0.001
Health knowledge
Frequency of reading newspaper
At least once a week (Ref) 3773 (14.2) 1.00 1.00
Less than once a week 9402 (35.4) 1.85 (1.52-2.26) < 0.001 1.02 (0.82-1.27) 0.84
Never 13376 (50.3) 5.49 (4.50-6.71) < 0.001 1.50 (1.20-1.86) < 0.001
Frequency of listening to radio
At least once a week (Ref) 8668 (32.6) 1.00
Less than once a week 9369 (35.2) 1.22 (1.06-1.40) 0.01
Never 8509 (32.0) 2.06 (1.77-2.39) < 0.001
Frequency of watching television
At least once a week (Ref) 20634 (77.6) 1.00 1.00
Less than once a week 3715 (14.0) 2.50 (2.17-2.89) < 0.001 1.25 (1.07-1.46) < 0.01
Never 2205 (8.3) 5.23 (4.35-6.28) < 0.001 1.62 (1.34-1.94) < 0.001
Knowledge of pregnancy complications
Yes (Ref) 11867 (44.6) 1.00 1.00
None 14717 (55.3) 2.73 (2.43-3.08) < 0.001 1.46 (1.25-1.70) < 0.001
Knowledge of delivery complications
Yes (Ref) 13133 (49.4) 1.00 1.00
None 13454 (50.6) 2.40 (2.15-2.68) < 0.001 1.19 (1.04-1.36) 0.01
Knowledge of post delivery complications
Yes (Ref) 8518 (32.0) 1.00
None 18063 (67.9) 2.10 (1.87-2.37) < 0.001
ENABLING FACTORS
Know where to go to seek health services
Small problem (Ref) 25166 (94.6) 1.00
Big problem 1403 (5.3) 2.24 (1.82-2.77) < 0.001
Permission to visit health services
Small problem (Ref) 25352 (95.3) 1.00
Big problem 1215 (4.6) 2.36 (1.93-2.88) < 0.001
Money to pay health services
Small problem (Ref) 19662 (73.9) 1.00 1.00
Big problem 6909 (26.0) 2.49 (2.21-2.80) < 0.001 1.21 (1.05-1.39) 0.01
Distance to health services
Small problem (Ref) 22580 (84.9) 1.00 1.00
Big problem 3989 (15.0) 2.76 (2.39-3.18) < 0.001 1.21 (1.03-1.42) 0.02
Titaley et al. BMC Public Health 2010, 10 :485
http://www.biomedcentral.com/1471-2458/10/485
Page 6 of 10
-
8/9/2019 Penelitian Anc Di Indonesia
7/10
Table 1 Baseline characteristics, unadjusted and adjusted odds ratio (OR) for factors associated with underutilization
of antenatal care services in Indonesia, IDHS 2002/2003 and 2007 (Continued)
Transportation to health services
Small problem (Ref) 22975 (86.4) 1.00
Big problem 3593 (13.5) 2.91 (2.51-3.38) < 0.001
Presence of companion
Small problem (Ref) 23688 (89.1) 1.00 1.00
Big problem 2878 (10.8) 1.84 (1.58-2.14) < 0.001 1.22 (1.01-1.47) 0.04
Availability of care by female health workers
Small problem (Ref) 24338 (91.5) 1.00 1.00
Big problem 2210 (8.3) 1.58 (1.31-1.90) < 0.001 1.29 (1.04-1.59) 0.02
NEED FACTORS
Pregnancy complications
With complications (Ref) 2349 (8.8) 1.00 1.00
No complications 24201 (91.0) 1.78 (1.46-2.17) < 0.001 1.44 (1.16-1.78) < 0.01
Desire for pregnancy
Wanted then (Ref) 21560 (81.1) 1.00 1.00
Wanted later 2907 (10.9) 1.46 (1.24-1.71) < 0.001 1.38 (1.14-1.67) < 0.01
Unwanted 2044 (7.7) 1.82 (1.52-2.17) < 0.001 1.42 (1.13-1.78) < 0.01
Note:
*) The total number varies between categories because of missing values) 1407 missing cases were excluded from the analysis
All values are weighted by the sampling probability
Ref: reference group
1
2
3
4
5
6
7
8
9
10
tserooPelddiMtseihtlaeW
Household wealth index
Completed secondary education or higher
Completed primary or some secondary education
Incomplete primary education or none
Household wealth index
Adjustedoddsratio
Ref
Figure 2 Odds ratio of combined maternal education and household wealth index for underutilization of antenatal care services. Note:
a. Ref: reference group. b. Model adjusted for year of survey, region and type of resident, maternal age at delivery, paternal education, maternal
marital status, maternal final say on her own health care, birth rank and interval, maternal frequency of reading newspaper, maternal frequency
of watching television, maternal knowledge of pregnancy complications and maternal knowledge of delivery complications.
Titaley et al. BMC Public Health 2010, 10:485
http://www.biomedcentral.com/1471-2458/10/485
Page 7 of 10
-
8/9/2019 Penelitian Anc Di Indonesia
8/10
assess its effectiveness in reaching the target population.Efforts to strengthen community financing mechanisms
might also help women from low economic status
households to access health services [36].
Low household economic status is correlated with low
education level [37]. This study demonstrated a strong
association between low maternal education and under-
utilization of antenatal service. The relationship between
maternal education and health service utilization was
also reflected by increased odds among mothers with
lack of knowledge of obstetric complications and lack of
exposure to mass media, as reported in previous
literature [18,38]. Moreover, our study confirmed thatlack of knowledge about the importance of maternal
and child health hinders women from attending antena-
tal services. Women reporting not having any pregnancy
complications had an increased odds of underutilizing
antenatal care services. This might be because they felt
well during pregnancy and therefore did not perceive
the need to attend any services. Several pathways have
been suggested through which maternal education
might affect health care utilization, including greater
knowledge of the importance of health services among
highly educated women and the increased ability to
Table 2 Adjusted Population Attributable Risk (PAR) for selected risk factors, IDHS 2002/2003 and 2007*
VARIABLE % aOR PAR (95%CI)
Region and type of residence
Java-Bali region: urban (Ref) 0.14 1.00
Java-Bali region: rural 0.30 2.78 0.19 (0.13 0.25)
Sumatera region: urban 0.05 1.63 0.02 (0.01 0.04)
Sumatera region: rural 0.21 4.60 0.16 (0.13 0.20)
Eastern Indonesia region: urban 0.06 2.39 0.03 (0.01 0.07)
Eastern Indonesia region: rural 0.24 4.93 0.19 (0.16 0.22)
Combined risk 0.48 (0.38 0.58)
Household wealth index and maternal education
Wealthiest household, completed secondary education or higher (Ref) 0.03 1.00
Wealthiest household, completed primary or some secondary education 0.08 2.15 0.04 (0.03 0.06)
Wealthiest household, incomplete primary education or none 0.02 4.01 0.02 (0.01 0.03)
Middle household wealth, completed secondary education or higher 0.03 2.36 0.02 (0.01 0.03)
Middle household wealth, completed primary or some secondary education 0.20 3.13 0.14 (0.10 0.17)
Middle household wealth, incomplete primary education or none 0.11 5.50 0.09 (0.07 0.11)
Poorest household, completed secondary education or higher 0.02 4.30 0.02 (0.01 0.02)
Poorest household, completed primary or some secondary education 0.25 4.75 0.20 (0.16 0.23)
Poorest household, incomplete primary education or none 0.25 8.82 0.22 (0.18 0.25)
Combined risk 0.55 (0.46 0.63)
Birth rank and interval
2nd or 3rd birth rank, > 2 year interval (Ref) 0.33 1.00
1st birth rank 0.25 0.81
2nd or 3rd birth rank, 2 year interval 0.08 1.94 0.04 (0.03 0.05)
4 th birth rank, > 2 year interval 0.28 2.08 0.15 (0.12 0.18)
4 th birth rank, 2 year interval 0.06 3.79 0.05 (0.03 0.06)
Combined risk 0.22 (0.17 0.27)
Knowledge of pregnancy complications
Yes (Ref) 0.26 1.00
None 0.74 1.46 0.23 (0.14 0.31)
Distance to health services
Small problem (Ref) 0.73 1.00
Big problem 0.27 1.21 0.05 (0.01 0.09)
Note:
*) These PAR values should not be added. If necessary, only the lower limit of the PAR could be added to provide conservative estimate about the potential
prevention due to the elimination of multiple risk factors [29];) Weighted by the sampling probability) aOR = adjusted odds ratio
Ref: reference group
Titaley et al. BMC Public Health 2010, 10:485
http://www.biomedcentral.com/1471-2458/10/485
Page 8 of 10
-
8/9/2019 Penelitian Anc Di Indonesia
9/10
select the most appropriate service for their needs
[37,39]. As reflected by the high PAR of combined low
household wealth index and low maternal education sta-
tus, health promotion programs targeting low educated
mothers from financially deprived households about the
importance of antenatal services will be beneficial to
increase the uptake of these services.
Similar to our findings, the association between high
parity and low utilization of health services has been
reported in another study from Turkey [40]. Women
with high parity might tend to rely on their experiences
from previous pregnancies and not feel the need for
antenatal checks [18,40]. Some might experience
difficulties to attend antenatal services due to time con-
straints related to their responsibilities for their other
children [18,34,40].
Other factors associated with antenatal care utilization
found in our study included maternal desire for preg-nancy and womens autonomy. Women w ith an
unwanted pregnancy are more likely to underutilize
antenatal services [41]. Unwanted pregnancies are asso-
ciated with late start or less frequent antenatal visits
compared to wanted pregnancies [16,41]. Moreover, our
study showed that women who were not involved in the
final decision making about their own health care were
more likely to underutilize antenatal services. An
increased likelihood for underutilizing antenatal services
was found in women who were the only decision maker
about their own health care, compared to those who
involved others in the decision making. This finding
showed the vital role of family support in utilizing
health services. It also indicates that public health strate-
gies should target not only the pregnant women but also
other family members to increase their awareness about
the importance of antenatal services.
Strengths and limitations
This present study was based on large representative
national surveys, the 2002/2003 and 2007 IDHS. The
potential of recall bias has been minimized by restricting
the sample only to mothers most recent delivery within
the last five years of each survey. The large sample used
in this study allows the examination of various potentialrisk factors, the external environment, predisposing,
enabling, and need factors. This also increased the valid-
ity of the study results. The following limitations of our
study should be kept in mind when interpreting the
results. As with other cross-sectional survey data, the
interpretation of the causality of factors associated with
underutilization of antenatal care is restricted by the
study design. The information used is also subject to
recall bias, as information collected relied on the
womens recall ability about her pregnancy. The selec-
t io n o f potential r is k f acto rs w as driven b y the
availability of information in each IDHS. Furthermore,
some variables were not infant-specific, such as parental
occupation, since they informed the employment status
of parents within one year prior to the survey. However,
these limitations are unlikely to impact on the validity
of the analyses.
Conclusions
Our study found significant associations between exter-
nal environment, predisposing, enabling and need fac-
tors and underutilization of antenatal care services.
Strategies to increase the accessibility and availability of
health care services should be a priority in Indonesia,
particularly in rural areas. As reflected by the PAR
results, it is important for health promotion programs
to target women with low levels of education and from
poor households to increase their awareness about the
importance of antenatal services and to increase theiruptake of these services. Financial support that enables
mothers from poor households to use health services
will be beneficial to reduce their out-of-pocket expendi-
ture for both medical and transportation costs. Evalua-
tion and monitoring strategies of the current financial
supports are important to assess their effectiveness in
reaching the target population.
Acknowledgements
We are grateful to the Australian Agency for International Development
(AusAID) for funding CRT PhD scholarship in International Public Health at
the Sydney School of Public Health, University of Sydney, Australia. This
analysis is part of CRT thesis. CLR is supported by a NHMRC ResearchFellowship.
Author details1Sydney School of Public Health, Edward Ford Building (A27), University of
Sydney, NSW 2006, Australia. 2The Kolling Institute of Medical Research,Royal North Shore Hospital, University of Sydney, St Leonards, NSW 2065,
NSW, Australia.
Authors contributions
CRT and MJD participated in the design of the study. CRT performed the
analysis and prepared the manuscript. MJD and CLR provided data analysis
advice and revision of the manuscript. All authors read and approved the
final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 23 March 2010 Accepted: 16 August 2010
Published: 16 August 2010
References
1. World Health Organization:Neonatal and perinatal mortality: country,
regional and global estimates. World Health Organization 2006.
2. Lawn JE, Cousens S, Zupan J, Lancet Neonatal Survival Steering Team:
4 million neonatal deaths: When? Where? Why? Lancet2005,
365(9462):891-900.
3. Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L, LancetNeonatal Survival Steering Team: Evidence-based, cost-effective
interventions: how many newborn babies can we save? Lancet2005,
365(9463):977-988.
Titaley et al. BMC Public Health 2010, 10:485
http://www.biomedcentral.com/1471-2458/10/485
Page 9 of 10
-
8/9/2019 Penelitian Anc Di Indonesia
10/10
4. World Health Organization:The World Health Report: 2005: Make Every
Mother and Child Count. Geneva: World Health Organization 2005.
5. Child Health Research Project:Reducing Perinatal and Neonatal Mortality.
Baltimore, Maryland: John Hopkins University1999.6. Chen X-K, Wen SW, Yang Q, Walker MC:Adequacy of prenatal care and
neonatal mortality in infants born to mothers with and without
antenatal high-risk conditions. Australian & New Zealand Journal ofObstetrics & Gynaecology2007, 47(2):122-127.
7. Petrou S, Kupek E, Vause S, Maresh M:Antenatal visits and adverse
perinatal outcomes: results from a British population-based study.
European Journal of Obstetrics, Gynecology, & Reproductive Biology2003,
106(1):40-49.
8. Raatikainen K, Heiskanen N, Heinonen S: Under-attending free antenatal
care is associated with adverse pregnancy outcomes. BMC Public Health
2007,7 :268.
9. Titaley C, Dibley M, Agho K, Roberts C, Hall J:Determinants of neonatal
mortality in Indonesia. BMC Public Health 2008,8(1):232.
10. Titaley C, Dibley M, Roberts C, Agho K: Iron/folic acid supplements protect
against early neonatal mortality in Indonesia. Bull World Health Organ
2010,88:500-508.
11. Coria-Soto IL, Bobadilla JL, Notzon F:The Effectiveness of Antenatal Carein Preventing Intrauterine Growth Retardation and Low Birth Weight
Due to Preterm Delivery. Int J Qual Health Care 1996, 8(1):13-20.
12. Bloom S, Lippeveld T, Wypij D:Does antenatal care make a difference tosafe delivery? A study in urban Uttar Pradesh, India. Health Policy Plan
1999,14(1):38-48.
13. Ram F, Singh A: Is antenatal care effective in improving maternal health
in rural Uttar Pradesh? Evidence from a district level household survey.
Journal of Biosocial Science 2006,38(04):433-448.
14. Badan Pusat Statistik-Statistics Indonesia (BPS) National Family Planning
Coordinating Board Ministry of Health ORC Macro: Indonesia Demographic
and Health Survey 2070. Calverton, Maryland: BPS and ORC Macro 2008.
15. Ministry of Health Republic of Indonesia: Indonesia Health Profile 2007.
Jakarta: Ministry of Health Republic of Indonesia2007.16. Magadi MA, Madise NJ, Rodrigues RN: Frequency and timing of antenatal
care in Kenya: explaining the variations between women of different
communities.Social Science & Medicine 2000,51(4):551-561.
17. Navaneetham K, Dharmalingam A: Utilization of maternal health care
services in Southern India. Social Science & Medicine 2002,
55(10):1849-1869.18. Pallikadavath S, Foss M, Stones RW:Antenatal care: provision and
inequality in rural north India. Social Science & Medicine 2004,
59(6):1147-1158.
19. Overbosch GB, Nsowah-Nuamah NNN, van den Boom GJM, Damnyag L:
Determinants of Antenatal Care Use in Ghana. J Afr Econ 2004,
13(2):277-301.
20. Measure DHS: Demographic and Health Surveys. [http://www.
measuredhs.com/countries/country_main.cfm?ctry_id=17&c=Indonesia].21. Macro International Inc:Sampling manual. DHS-III Basic Documentation No
6 Calverton, Maryland 1996.
22. Badan Pusat Statistik-Statistics Indonesia (BPS) National Family Planning
Coordinating Board Ministry of Health ORC Macro: Indonesia Demographicand Health Survey 2002-2003. Calverton, Maryland: BPS and ORC Macro
2003.
23. Andersen RM:Revisiting the behavioral model and access to medical
care: does it matter? Journal of Health & Social Behavior1995, 36(1):1-10.
24. Filmer D, Pritchett LH:Estimating wealth effects without expendituredataor tears: an application to educational enrollments in states of
India. Demography2001,38(1):115-132.
25. Victora CG, Huttly SR, Fuchs SC, Olinto MT:The role of conceptual
frameworks in epidemiological analysis: a hierarchical approach. Int J
Epidemiol1997, 26(1):224-227.26. Jekel JF, Katz DL, Elmore JG:Epidemiology, Biostatistics, and Preventive
MedicinePhiladelphia: W.B. Saunders Company, 2 2001.
27. Rockhill B, Newman B, Weinberg C:Use and misuse of populationattributable fractions. Am J Public Health 1998, 88(1):15-19.
28. Steenland K, Armstrong B:An overview of methods for calculating the
burden of disease due to specific risk factors. Epidemiology2006,
17(5):512-519.
29. Rowe AK, Powell KE, Flanders WD:Why population attributable fractions
can sum to more than one. American Journal of Preventive Medicine 2004,
26(3):243-249.
30. Heywood P, Harahap N:Human resources for health at the district levelin Indonesia: the smoke and mirrors of decentralization. Human
Resources for Health2009,7(1):6.
31. Chen L, Evans T, Anand S, Boufford JI, Brown H, Chowdhury M, Cueto M,Dare L, Dussault G, Elzinga G, et al: Human resources for health:
overcoming the crisis. The Lancet2004, 364(9449):1984-1990.
32. King-Schultz L, Jones-Webb R:Multi-method approach to evaluate
inequities in prenatal care access in Haiti. Journal of Health Care for the
Poor and Underserved2008, 19(1):248-257.
33. Titaley CR, Hunter CL, Dibley MJ, Heywood P:Why dont some women
attend antenatal and postnatal care services?: a qualitative study in
Garut, Sukabumi and Ciamis districts of West Java province, Indonesia.
BMC Pregnancy and Childbirth (under review) .
34. Simkhada B, van Teijlingen ER, Porter M, Simkhada P:Factors affecting the
utilization of antenatal care in developing countries: systematic review
of the literature. Journal of Advanced Nursing 2008, 61(3):244-260.
35. Furuta M, Salway S:Womens Position within the Household as a
Determinant of Maternal Health Care Use in Nepal. International FamilyPlanning Perspectives 2006,32(1):17-27.
36. Lagarde M, Haines A, Palmer N:Conditional Cash Transfers for Improving
Uptake of Health Interventions in Low-and Middle-Income Countries: ASystematic Review. JAMA2007, 298(16):1900-1910.
37. Ware H:Effects of Maternal Education, Womens Roles, and Child Care
on Child Mortality. Population and Development Review1984,
10(Supplement):191-214.
38. Titaley CR, Dibley MJ, Roberts CL:Factors associated with non-utilization
of postnatal care services in Indonesia. J Epidemiol Community Health
2009, jech.2008.081604.
39. Matsumura M, Gubhaju B:Womens status, household structure and the
utilization of maternal health services in Nepal. Asia-Pacific Population
Journal2001, 16(1):23-44.
40. Celik Y, Hotchkiss DR:The socio-economic determinants of maternalhealth care utilization in Turkey. Social Science & Medicine 2000,
50(12):1797-1806.
41. Gabrysch S, Campbell O:Still too far to walk: Literature review of thedeterminants of delivery service use. BMC Pregnancy and Childbirth 2009,
9(1):34.
Pre-publication history
The pre-publication history for this paper can be accessed here:
http://www.biomedcentral.com/1471-2458/10/485/prepub
doi:10.1186/1471-2458-10-485
Cite this article as: Titaley et al.: Factors associated with underutilizationof antenatal care services in Indonesia: results of IndonesiaDemographic and Health Survey 2002/2003 and 2007. BMC Public Health2010 10 :485.
Submit your next manuscript to BioMed Centraland take full advantage of:
Convenient online submission
Thorough peer review
No space constraints or color figure charges
Immediate publication on acceptance
Inclusion in PubMed, CAS, Scopus and Google Scholar
Research which is freely available for redistribution
Submit your manuscript atwww.biomedcentral.com/submit
Titaley et al. BMC Public Health 2010, 10:485
http://www.biomedcentral.com/1471-2458/10/485
Page 10 of 10